City of Cambridge PAL Card Application

Required fields are marked with asterisks (*)

Application Type (New/Renewal)

Old card number

If renewing the application. Reason for renewal:

First Name & Last Name

Date of Birth

Applicant's Age

Home Address

City/Town

Postal Code

Phone

Email Address

Is the disability?

Temporary

Permanent

If Temporary, how long do you anticipate the disability to last?

Is the disability eliminated by the use of technical aid (e.g. eyeglasses?)?

Yes

What is a PAL Card? For some people with disabilities, it is impossible to go places without someone’s help. A PAL (Personal Attendant for Leisure) Card allows people with disabilities to be accompanied by an attendant – free of charge.

The PAL Card:
1. Identifies that the person named on the card requires the assistance of an accompanying personal attendant. All regular program fees/registration fees apply.
2. Authorizes that the accompanying personal attendant will not be charged Registration or Admission.

References:

Please notify references of your application.Only list places of business (personal home phone numbers are not acceptable).

Reference Name 1

Reference 1 Occupation

Reference 1 Email

Reference 1 Phone

Reference 2 Name

Reference 2 Occupation

Reference 2 Email

Reference 2 Phone

Card Delivery Preference* (Complimentary Mailing Service via Canada Post)

By Mail

Pick Up form City Hall

At present, the City of Cambridge Equity, Diversity, Inclusion and Accessibility Services, do not require a medical certificate for PAL Card eligibility. However, it is necessary to have verification that the applicant has a disability. Therefore, references are required..

The references must have worked directly with the applicant in a professional capacity and should be able to verify the applicant's disability.

Acceptable References include physicians, therapeutic recreationists, occupation therapists or physiotherapists, speech-language pathologists, teachers, clergy, etc. All references will be contacted by the City of Cambridge, Corporate Services Department staff before the PAL Card application is approved. If you wish, you may submit written verification along with your application from any of the acceptable references listed above.

Personal information collected during this process is authorized under the Municipal Freedom of Information and Protection of Privacy Act. This information will be used solely for its intended purpose.

If you have any questions regarding this process or the collection of personal information, please contact (519) 740-4680, extension 4782 or at accessibility@cambridge.ca

I, confirm that the information provided above is, to the best of my knowledge, accurate and complete. I understand that the Corporate Services Department of the City of Cambridge will reach out to my references. I also acknowledge that the approval of this application is contingent upon verifying that I am a person with a disability who requires an attendant.

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